Endovascular repair

<!-- type: treatment -->

**Endovascular repair (covered stent-graft exclusion)**

Covered stent-grafts can exclude a PAApopliteal artery aneurysm (PAA) with lower early physiologic stress and shorter recovery in selected patients, but durability is sensitive to anatomy and knee-flexion biomechanics across the popliteal segment. [@esc2017] [@tielliu2005] [@cassar2005] [@troisi2025]

**When to consider endovascular repair**

- Elevated operative risk or limited life expectancy. [@esc2017]
- No adequate autologous vein conduit. [@esc2017] [@rutherford2018-rutherford]
- Favorable anatomy:

  - Adequate proximal/distal landing zones. [@esc2017]
  - Acceptable runoff, or a plan to address tibial disease/embolization when present. [@esc2017]

**Limitations and expected outcomes**

- Compared with vein bypass, endovascular repair often has **higher reintervention rates** and **inferior long-term primary patency** in many series and reviews, emphasizing the need for careful patient selection and surveillance. [@huang2007] [@esc2017]
- Early series commonly report ~60-70% primary patency at approximately 3 years, with secondary interventions improving limb outcomes.outcomes; recent cohort data on self-expandable covered stents continue to support these findings in late-term follow-up. [@tielliu2005] [@huang2007] [@troisi2025]

**Antithrombotic therapy (pragmatic)**

- Antiplatelet therapy is generally used after lower-extremity endovascular interventions; dual-pathway inhibition (low-dose rivaroxaban plus aspirin) reduces major adverse limb events after revascularization in appropriate patients but must be balanced against bleeding risk. [@ahaacc2016] [@voyager2020]

**Surveillance requirement**

- Endovascular PAA repair mandates **more intensive duplex surveillance** than elective open bypass because of edge stenosis, thrombosis risk, and potential deformation with knee flexion. [@esc2017] [@troisi2025]